Changing the Standards

Alberto Salvatore, AIA, NCARB

Changing the standards

"Beneath her invocation of statistics lay ideas much older and more traditional. These ideas reflected a vision of the world in which volition and disease, environment and regimen, body and mind were woven together so as to create a meaningful structure into which health, and healing, and disease could be placed."—Florence Nightingale, 1860

Since 1993, The Center for Health Design has initiated many efforts to heighten the awareness of healthcare providers and designers of the positive effects of the built environment on health and well-being. In 1998, these efforts influenced a series of recommendations to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to modify the Management of the Environment of Care Guidelines to include key elements and issues relative to improving the quality of the environment to support well-being. These recommendations were an outcome of a task force of the center's Environmental Quality Standards Work Group. This task force was made up of an interdisciplinary group of healthcare professionals including a systems engineer, researchers, nurses, a physician, architects, a landscape architect and interior designers.

As a continuation of the efforts of the Environmental Quality Standards Work Group, the Environmental Standards Council (ESC) of the center has developed a document that describes key elements and issues that are critical to developing an appropriate environment of care. This document first identifies the physical environment as only one of the six components that define the environment of care. These six components are:

The document then elaborates on the key elements and issues within the physical environment that are essential to the appropriate development of that environment, which include:

* Light and views* Wayfinding/clarity of access* Control of the environment* Privacy* Security and safety* Color* Cultural responsiveness* Reducing waste and toxicity

This document has been presented for consideration to the Health Guidelines Revision Committee (HGRC), which will review proposed modifications and additions to the 2005 edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities. The challenge that is now before us is to use the research and knowledge developed by these efforts to further affect change and recognition by all who are involved in the development of healthcare environments. Some of the specific questions that can be asked are as follows:Question 1: How can the physical environment enhance patients' experience and outcomes in the delivery of healthcare?

Qualitative focus group research done by The Picker Institute for the center found that the elements that matter most to patients can be summarized in eight themes. Patients want a built environment that:

* Promotes connections to staff;* is conducive to well-being;* is convenient and accessible;* is confidential and private;* shows caring for family;* is considerate of impairments;* facilitates connection to the outside world; and* is safe and secure.

From this research, the center produced a "Patient Centered Environmental Checklist," part of the Action Kit that identifies specific elements to evaluate in each of the above stated categories. This tool is a great start toward developing a better understanding of how to create a patient/family centered environment.Question 2: How can the built environment enhance patient flow, overall efficiencies and functional operation?

Efficiencies in patient flow and overall functional operation are directly related to appropriate adjacencies, size, configuration and environment created by the allocation of spaces. Clinical philosophies, operational strategies and physical environment need to be addressed concurrently to maximize the efficiencies that will result for the system as a whole. If any one component is separated and addressed without consideration of the other, the opportunity for greatest performance and best outcome is immediately compromised.

For example, clear, orienting circulation paths with memorable events and comfortable seating along the journey from entry to exam or procedure/testing areas go a long way to getting patients to their proposed destination on time and in the correct frame of mind—which allows the care to be delivered most efficiently and with improved outcomes. In a large, interdisciplinary, full-service medical center, this is an extremely important element for patients, family and visitors.

ENVIRONMENTAL STANDARDS COUNCIL

The following professionals are members of The Center for Health Design's Environmental Standards Council:

Question 3: What are the space implications associated with the key elements/ issues for the built environment?

The key elements/issues in general have a direct impact on everything from the image of the overall project to the community and the users to the programming of the site and the buildings. Three examples are as follows:

* The project site needs to be programmed to accept the appropriate amount of square footage of space to support the functional programs to be located there (clinical, research, education, amenities). It also has to accommodate the parking requirements associated with these functions. Implied in the key elements/ issues is the creation of vital natural environments that support well-being. The landscaping that is used to emphasize the general sense of arrival and support wayfinding, as well as the development of private contemplative gardens and exterior play areas, must be programmed into the project as line items in the initial cost estimates or they will never remain part of the project that actually gets built. Conclusion: Every strategic and operational decision has a physical and functional consequence.

* Accommodating family members in the patient rooms and including them as part of the "care team" directly impacts the space requirements of that room (needs to be larger; it also affects the policy and procedures and functional operation of the unit by the nursing staff, doctors and allied health professionals). Conclusion: The strategic decision relative to single versus semi-private rooms, as well as the concept of family-centered care, is directly affected by the key elements/issues of the built environment.

* Horizontal versus vertical integration of clinical, research and education space, along with concepts of centralized versus decentralized functions, impact the scale and resulting spaces that people walk through. The "space in-between" is always the most important outcome of any project. The space that people walk through, on the exterior between the buildings; the spaces they walk through to get to their destination in the hospital; and the actual outpatient exam or inpatient clinical spaces where care is delivered are the essence of the project. Are these spaces vital, secure and comforting or cold, sterile and disconcerting? Conclusion: The relative configuration and distribution of the functional area (square footage) associated with each of the program elements are also directly affected by the key elements/issues of the built environment.

The center's ESC is also working on the development of an awards program that will encourage excellence in the design of medical equipment. The ESC remains an interdisciplinary group of dedicated professionals committed to working toward the improvement of the patient experience and outcome through the development of more appropriate physical environments.

History has shown that the most successful projects are born with a healthy respect for what has come before and a clear vision of what the future wants them to be. When all is said and done, the evidence of our successful process will not only be the increased quality and access to care for all who need it, it will also be the culturally responsive spaces and facility presence, warmth and caring that the community, patients, families, visitors and staff feel in their experience of the care environments from all the health centers across the country.

Alberto Salvatore, AIA, NCARB, is principal of Alberto Salvatore Associates, Needham, MA. With over 20 years of healthcare design experience, Salvatore has led both the JCAHO and the HGRC efforts for The Center for Health Design and is the national leader in the development of the Interdisciplinary Design Team (IDT) approach to project delivery. He can be reached at asalvatore@attbi.com.